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You are the manager of the Medical Records Department at Rasmussen Hospital and were recently reviewing the organization’s current Document Retention Policy (linked below).

  • Download: Document Retention Policy Click for more options

The current policy addresses the retention and destruction of medical records in the normal course of business. However, you noticed that it does not include instructions for how employees should respond to a litigation hold. Ultimately, the policy will need to be updated, but in the meantime, you decide to create a short training document to educate the staff.


In a two (2) page training document, written using proper spelling and grammar, as well as professional tone and vocabulary, address the items below.

  1. Differentiate between the three (3) legal terms below by explaining each and comparing them to one another.
    1. Litigation Hold
    2. Notice of Preservation
    3. Order for Preservation
  2. Provide instructions explaining how the staff should handle a litigation hold.

Your training document should be well organized and include appropriate headings/subheadings. Be sure to incorporate and cite at least one (1) credible, scholarly resource using APA format.

Rasmussen Hospital: Medical Record Management

Policy # Policy Title: Effective Date: Revision Date: Forms #:


Document Retention 10/23/2003 05/01/2019

It is the policy of Rasmussen Hospital to apply appropriate and cost effective management techniques to maintain complete and accurate records. Records are retained in accordance with all applicable laws and regulations and this policy. The purpose of this policy is to establish the policy and procedures for the creation, use, maintenance, retention, preservation and disposal of Rasmussen Hospital’s records in order to:

1) Meet current Company needs in record storage (or other electronic media) and retrieval systems

2) Ensure compliance with the various governmental regulations concerning document retention

3) Ensure uniformity in records retention throughout the Company

1) Records shall not be destroyed before the prescribed retention period has expired. Records shall not be retained for longer than the prescribed period without first contacting the applicable department head.

2) Retention periods are specified for original documents only, unless otherwise specified. Duplicates of original documents should generally be properly destroyed after use, unless the retention of such duplicate original document is necessary to support current operations. If duplicates are retained, they should be properly destroyed after they have served their purpose.

3) Records containing confidential and proprietary information will be securely maintained, controlled and protected to prevent unauthorized access.

4) All records generated and received by Rasmussen Hospital are the property of Rasmussen Hospital. No Rasmussen Hospital employee, by virtue of his or her position, has any personal or property right to such records even though he or she may have developed or compiled them.

5) Any unauthorized destruction, removal or use of such records is strictly prohibited.

6) No person shall falsify or inappropriately alter information in any record or document. Information pertaining to unauthorized destruction, removal or use of Rasmussen Hospital records or regarding falsifying or inappropriately altering information in a record or document must be reported to management.

General Information

Page 1 of 5

Rasmussen Hospital: Medical Record Management Policy 6.01 Document Retention


The following special considerations apply to the application of Rasmussen Hospital Document Retention policy and procedure.

  1. 1)  Records Relevant to more than one category When records may be subject to more than one category and corresponding retention period, employees must use the longest retention period.
  2. 2)  Copies Only one copy of each record must be retained to comply with record retention requirements.
  3. 3)  Exceptions Any exceptions to Rasmussen Hospital’s Document Retention policy and procedure may be made only after consultation with the Compliance or Legal Department.
  4. 4)  Assistance Employees should never guess as to the retention period applicable to a particular record or category of records. Any questions in this regard should be directed to the Supervisor/Manager who shall consult with the Compliance or Legal Department as appropriate.

Last Reviewed: 05/01/2019

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Rasmussen Hospital: Medical Record Management Policy 6.01 Document Retention Rasmussen Hospital Document Retention Resource

Record Type

Medical Records of Patients

Medical Records of Patients – Minors

Retention Period

10 years from date of discharge

10 years from the date the minor turns 18 years of age

Current +7 Years

Current Year + 2 years Current Year + 1 year


Follow state regulations regarding Medical Record retention when stricter

Follow state regulations regarding Medical Record retention when stricter

From policies 5.25, 5.26 and 5.30


Per HIPAA Policy H-21A procedure 5

Any items scanned and attached to electronic medical record

Until verification is completed by the patient service specialist to ensure all documents are scanned, attached to the electronic medical record and legible.

Appointment / Schedule Book

Current Year + 2 years

Patient schedules that are maintained or modified on paper must be retained as noted in“retention period”. Electronic schedules (i.e., TherapySource) that can be recalled from a computerized system are not required to be retained in a paper format.

Informed Consent General release Forms; Program Agreements/Release Waivers

Patient Sign-In Sheets Fax Cover Sheets

Daily Close Reconciliation Packet

  •   Co-pay pack (Co-pay Checklist /
    Daily Receivables log, TS Copay Collections Report, InstaMed Deposits Report, signed credit card receipts, scanned money orders)
  •   TS End of Day Reconciliation Report
  •   TS Completed Notes Report
  •   Accepted Visits / Rejected Visits
  •   RT Billing Coding Edit Report
  •   RT Billing Reconciliation Report
  •   Daily Charge Reconciliation
  •   Batch Information Report
  •   RT Charges Posting
    Reconciliation Report

Most current 15 months unless otherwise noted below

CBOs will retain for co-pay pack for 10 years with the exception of original credit card receipts.

Manual Charge Tickets

Until verification is completed by the patient service specialistto ensure all documents are

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Rasmussen Hospital: Medical Record Management Policy 6.01 Document Retention Rasmussen Hospital Document Retention Resource

Record Type

Organizational Charts

Signed staff time cards

Customer Complaint Forms Net Promoter Surveys

Clinical Operations Policy and Procedure Manual

Center Handbook Documents

Retention Period

scanned, attached to the electronic medical record and legible.

Until superseded by new organizational chart

Current + 1 year Current + 7 years

Current year + 6 years Most recent 4 quarters Current policies

Current + 1 year unless otherwise noted below

Term of Contract + 6 years

Term of employment + 5 years

Current + 7 years

Term of employment + 2 years

Term of employment + 2 years





Management reports (Examples: Income statements, KPI reports, referral tracking reports)

While useful in the center

Any reports generated from the RMT or Oracle system do not need to be retained in hard copy.

Administrative Logs (staff schedules, day-to-day management of office personnel / functions, petty cash requests)

Current + 3 years


Clinical Quality Assurance Audits

For audits completed by hand or Excel spreadsheets, maintain current year plus previous year.

Audits entered into the SM QA database, NA


  •   Equipment Calibration
  •   Safety Procedures pertaining to
    security of patients and/or
  •   Evacuation drill reports
  •   Safety Inspections of building or
  •   Meeting Minutes

Current year + 3 years.

Includes all records documenting the inspection of facilities for potential safety hazards

Contracts – Medical Director, Contract Employees and Lease Agreements

Personnel Files of Employees and other employee records (unless noted below)

  •   Employee Medical Records
  •   Performance Appraisals / Compensation Adjustments / Awards and recognition
  •   Company sponsored education

Keep the previous year’s records in a separate folder to decrease size of the Center Handbook.




Page 4 of 5

Rasmussen Hospital: Medical Record Management Policy 6.01 Document Retention Select Medical Outpatient Division Document Retention Resource

Record Type

Job related accidents and injuries

Employee Exposure Incidences or documents recording incident

Retention Period

Current Year + 5 years NA 30 Years NA

Permanent NA Permanent NA


 

Incident Reports

Record Destruction – records supporting the documentation of destruction of medical records

Destruction of Records:

a) Medical records shall be shredded or after they have been retained the greater of the following: i. Company policy as outlined in policy 6.01 (Document Retention),
ii. State law if more stringent, or
iii. Unique contractual requirements (if applicable)

b) Where required by law, notice of record destruction will be reported to the appropriate agency in accordance with stated statutes, rules and regulations.
c) The Regional Director or Market Manager shall be responsible for ensuring there is a mechanism to destroy the old records and that destruction is completed properly.
d) During the course of normal daily activities, parts of the patient’s medical record may be copied for business purposes. These copies shall be destroyed by shredding once their purpose is completed.

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  • a year ago
  • 09.01.2021
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